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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 KI JOB 20--3695-01 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. APN NOS. 137-340-01 and 137-340--23 Job Address 123 W. Sonora Street City Stockton Lot Size/Acreage Owner's Name N.Jay McCutchen Address 123 W. Sonora St. Stockton CA.--- Phone 466-9704 Contractor Spec trum/Kleinfelder Address 2825 E. Myrtle St. License No. 512263—Phone - TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n D'ESTR1TCt'*W-D'eat vtL--Ser+r4erV&:ki-lF4 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER XX MMA4GrR4oagrite1]r-0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PRGfL-L4p}E__2__test boT ings FOUNDATION AGRICULTURE WELL OTHER WELL pffseu mfr -at deep INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Gtr dia. 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation -0ia.�RaAlef4Laaing Cl Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ _S"c icatioc,s Na ground I'1 Public 1:1 Other n Delta Depth of Grout Seal -Type e}-C water t I Irrivation —Approx. Depth I I Eastern Surface Seal Installed by, anticipated. If Repair Work Done U Type of Pump H,P. State Work Done encountered will back ill Well Destruction ❑ Well Diameter Sealing Material & Depth with "hole plug" Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted it public sewer is available within 200 feet.l Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth (V SEPTIC TANK ❑ Type/Mfg Capacity--- No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C) No. i Length of lines Total length/site FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's campenss- tion laws of Callfor The applicant t II or MLTquired ' s 1' triplets drawing on reverse side. Signed �• Title: project Engineer Date: January 4, 1993 4LFO ARTMENT USE ONLY Application ACcaptad by Date /7 4 ~17 Area Pit or Grout inspection by Data Final Inspection by I f Dau Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED Zn CK H RECEIVED BY �DATE PERMIT'NO. . tH,ss,t�Ev.I,rs,�'!� Cs Z 7-1 �Q EH 1,-]!